Provider Demographics
NPI:1942320312
Name:R E WILLIFORD MD PA
Entity Type:Organization
Organization Name:R E WILLIFORD MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TARSHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-301-4264
Mailing Address - Street 1:PO BOX 788
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27402-0788
Mailing Address - Country:US
Mailing Address - Phone:336-343-7026
Mailing Address - Fax:336-633-0410
Practice Address - Street 1:230 FOUST STREET
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203
Practice Address - Country:US
Practice Address - Phone:336-633-0407
Practice Address - Fax:336-633-0410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 1041C0700X, 363LP0808X
NC9700286207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5906946Medicaid
NCG64874Medicare UPIN
NC200943Medicare ID - Type Unspecified